宫颈癌新辅助化疗的临床疗效

目的探讨宫颈癌术前应用新辅助化疗的临床疗效。方法 68例宫颈癌术前采用2个疗程的新辅助化疗后进行手术,观察近期疗效。结果 68例患者化疗2个疗程后的临床总有效率为70.1%。经过术前辅助化疗后,进行广泛性子宫切除加盆腔淋巴结清扫手术,全部患者均顺利切除病灶。结论术前新辅助化疗对宫颈癌Ⅰb1~Ⅱb期患者治疗安全有效,可缩小肿瘤体积,提高手术切除率及疗效,进一步改善患者的生活质量。     

An evaluation of consumer participation in hospital breast services

Community expectations and research demonstrate that consumers play an important role in shaping services for women with breast cancer. Consumer contribution has been mandated recently in Victoria, Australia, to ensure the inclusion of consumer involvement in the planning and decision‐making processes within health organizations. As part of the redevelopment of breast services in Victoria, Southern Health has been funded to plan local improvements to care co‐ordination for women diagnosed with breast cancer in the southern metropolitan area of Melbourne. The establishment of effective consumer participation in breast services is an integral aspect of this project and a range of initiatives has been undertaken to achieve meaningful consumer involvement including the appointment of a consumer advisor; appointment of staff with extensive knowledge in women's health and community development to the project; establishment of a consumer reference group; and plans made to improve the receptivity of health service systems to consumer input. A preliminary evaluation of this ongoing project has indicated that a productive role for consumers in service practice review and policy and planning activities has been established and some change and engagement of staff has occurred. There is still work to be done to promote the involvement of a wider range of health professionals and to increase the level of trust between consumers and staff.     

Is the Risk Comparison Made by the Public Between EMF and Smoking or Asbestos a Valid One?

The possibility of adverse health effects from exposure to extremely low frequency (ELF) electric and magnetic fields (EMF) has caused considerable controversy in the scientific community and has received great attention in the media and among the general public with many comparing ELF EMF with tobacco smoking and asbestos. Although both smoking and asbestos are now classified by the International Agency for Research on Cancer (IARC) as Group 1 or “established” carcinogens, this was not always the case. In this paper the evidence for the carcinogenicity of ELF EMF is compared with that for smoking and asbestos using the Bradford Hill model for establishing causality between exposure and disease. Application of the model shows that present data are insufficient to demonstrate that exposure to ELF EMF poses a definite human health hazard. However, while the bulk of the evidence is weak, there are several epidemiological studies which have reported an association between prolonged exposure to magnetic fields at levels above what is normally encountered and an increased risk in childhood leukaemia. On this basis IARC has classified ELF magnetic fields as a Group 2B or “possible” carcinogen.     

Healthcare costs in postmenopausal women with hormone-positive metastatic breast cancer

Abstract

Objectives:

This study examines costs for postmenopausal women with hormone receptor positive (HR+) metastatic breast cancer (mBC).

Methods:

Data were obtained from the IHCIS National Managed Care Benchmark Database from 1/1/2001 to 6/30/2006. Women aged 55–63 years were selected for the study if they met the inclusion criteria, including diagnoses for breast cancer and metastases, and at least two fills for a hormone medication. Patients were followed from the onset of metastases until the earliest date of disenrollment from the health plan or 6/30/2006. Patient characteristics were examined at time of initial diagnoses of metastases, while costs were examined post-diagnosis of metastases and prior to receipt of chemotherapy (pre-chemotherapy initiation period) and from the date of initial receipt of chemotherapy until end of data collection (post-chemotherapy initiation period). Costs were adjusted to account for censoring of the data.

Results:

The study population consisted of 1,266 women; mean (SD) age was 59.05 (2.57) years. Pre-chemotherapy initiation, unadjusted inpatient, outpatient, and drug costs were $4,392, $47,731, and $5,511, while these costs were $4,590, $57,820, and $38,936 per year, respectively, post-chemotherapy initiation. After adjusting for censoring of data, total medical costs were estimated to be $55,555 and $70,587 in the first 12 months and 18 months, respectively in the pre-chemotherapy initiation period. Post-chemotherapy initiation period, 12-month and 18-month adjusted total medical costs were estimated to be $87,638 and $130,738.

Limitations:

The use of an administrative claims database necessitates a reliance upon diagnostic codes, age restrictions, and medication use, rather than formal assessments to identify patients with post-hormonal women with breast cancer. Furthermore, such populations of insured patients may not be generalizable to the population as a whole.

Conclusions:

These findings suggest that healthcare resource use and costs – especially in the outpatient setting – are high among women with HR+ metastatic breast cancer.     

Cost impact of oral capecitabine compared to intravenous taxane-based chemotherapy in first-line metastatic breast cancer

Abstract

Objective: Few studies have examined the costs associated with differing first-line chemotherapy regimens in patients with metastatic breast cancer (MBC). This study compares the relative cost impact of women starting first-line chemotherapy with capecitabine versus taxanes.

Methods: Women receiving first-line chemotherapy for MBC from 1998 to 2002 were identified from a hybrid North Carolina Medicaid-claims-tumour registry linked database and Medicare records, and were followed through to 2005 with claims data. Statistical t- and chi-square tests were used to compare baseline characteristics between patients who received first-line chemotherapy with capecitabine versus taxanes. Projected mean costs for 12 months continuous eligibility were estimated using an ordinary least squares linear regression. Overall cost impact of capecitabine after start of therapy was then examined using a multivariate log-linear regression model.

Results: While patients starting taxanes had significantly lower total costs in the pre-index year than patients starting capecitabine (mean: $20,042 vs. $35,538, p<0.001), in the post-index year, the patients on taxanes experienced significantly higher healthcare utilisation and associated costs compared to patients on capecitabine (mean: $43,353 vs. $35,842, p=0.0089). The differences were primarily attributable to lower expenses in chemotherapy related claims and fewer visit days to outpatient settings for patients on capecitabine. After adjustment with propensity scores and other confounders, the capecitabine group was associated with 32% lower healthcare costs compared to the taxane group (p=0.0001).

Conclusions: In this population-based study, women who received capecitabine as first-line treatment for MBC had significantly lower costs compared to women starting taxane therapy.     

Cost-effectiveness implications of increased survival with anastrozole in the treatment of advanced breast cancer

Summary

Anastrozole (Arimidex*) has a survival benefit compared with megestrol acetate in postmenopausal women with advanced breast cancer who have failed on tamoxifen. It was felt appropriate that such a clinical finding should be subjected to economic evaluation.

A cost-effectiveness analysis was undertaken from the viewpoint of a third-party payer, of the data from a combined analysis of two clinical studies. The outcome measures were duration of drug treatment and life years gained. The incremental cost effectiveness ratio (ICER) of anastrozole was £1,608 per life year gained based on UK NHS drug prices in April 1998. Sensitivity analysis showed that the ICER could vary between £5 and £1,643, depending on relative drug costs in a number of countries, between £1,056 and £1,761, depending on the method used to calculate duration of treatment and survival, and could increase to £3,730, based on treatment provided during the extra period of survival.

Anastrozole is a highly cost-effective alternative to megestrol acetate for postmenopausal women with advanced breast cancer.     

Cervical cancer prevention in Morocco: a model-based cost-effectiveness analysis

Abstract

Objective: Cervical cancer is a huge public health issue in Morocco which represents the second most frequent and fatal cancer among women. Countries that have not yet introduced the HPV vaccine could benefit greatly, but before implementation it is necessary to perform country-specific economic assessments that include current screening practices.

Methods: A Markov model was developed to simulate the natural history of HPV and cervical cancer so as to calculate the long-term health benefits and costs of HPV vaccination and current screening by visual inspection with acetic acid (VIA). Starting from a previous transition probability matrix used for a model from Spain, the present model was calibrated to cervical cancer incidence from Morocco. Cost survey data was used to estimate the cost of screening and clinical procedures from the public healthcare perspective. Incremental cost-effectiveness ratios were calculated as 2018US$ per additional year of life saved (YLS) and both costs and health outcomes were discounted at 3%.

Results: The expected reduction in lifetime risk of cervical cancer for current screening would be 14% at a cost of US$551/YLS compared with no intervention, assuming VIA every 3 years in women aged 30–49 at 10% coverage. HPV vaccination of pre-adolescent girls at 70% coverage would reduce the lifetime risk of cervical cancer by 62% at a cost of US$1,150/YLS, compared with no intervention. When implementing HPV vaccination in combination with current screening, vaccination would be dominated, and the combined strategy would provide a 69% reduction at a cost of US$2,843/YLS, compared with screening alone. Current screening would be dominated by vaccination when screening coverage is higher than 15%, whereas the combined strategy rapidly exceeds US$4,000/YLS.

Conclusions: HPV vaccination could be highly effective and cost-effective in Morocco. Current screening would be good value for money compared with no intervention, but scaling-up screening coverage would make it inefficient compared with vaccination.     

The cost-effectiveness of alectinib in anaplastic lymphoma kinase-positive (ALK+) advanced NSCLC previously treated with crizotinib

Introduction Anaplastic lymphoma kinase (ALK) targeting drugs provide an important option for advanced non-small cell lung cancer patients with this distinct tumor type; however, there is considerable uncertainty as to which drug provides the optimal value after crizotinib treatment. This study estimated the cost-utility of alectinib vs ceritinib from a US payer perspective.

Methods A cost-utility model was developed using partition survival methods and three health states: progression-free (PF), post-progression (PP), and death. Survival data were derived from the key clinical trials (alectinib: NP28761 &; NP28673, ceritinib: ASCEND I and II). Costs included drugs, adverse events, and supportive care. Utilities were based on trial data and the literature. One-way and probabilistic sensitivity analyses (PSA) were performed to assess parameter uncertainty.

Results Treatment with alectinib vs ceritinib resulted in increases of 2.55 months in the PF state, 0.44 quality adjusted life-years (QALYs), and $13,868, yielding a mean cost/QALY of $31,180. In the PSA, alectinib had a 96% probability of being cost-effective at a willingness-to-pay of $100,000/QALY. Drivers of model results were drug costs and utilities in the PF health state. The ICER ranged from $10,600–$65,000 per QALY in scenario analyses, including a sub-group analysis limited to patients with prior chemotherapy and crizotinib treatment.

Conclusions Treatment with alectinib in ALK?+?crizotinib-treated patients increased time progression-free and QALYs vs ceritinib. The marginal cost increase was driven by longer treatment durations with alectinib. This model demonstrates that alectinib may be considered a cost-effective treatment after progression on crizotinib.     

Projecting total costs and health consequences of increasing mt-sDNA utilization for colorectal cancer screening from the payer and integrated delivery network perspectives

Abstract

Aims: To evaluate total costs and health consequences of a colorectal cancer (CRC) screening program with colonoscopy, fecal immunochemical tests (FIT), and expanded use of multitarget stool DNA (mt-sDNA) from the perspectives of Integrated Delivery Networks (IDNs) and payers in the United States.

Materials and methods: We developed a budget impact and cost-consequence model that simulates CRC screening for eligible 50- to 75-year-old adults. A status quo scenario and an increased mt-sDNA scenario were modeled. The status quo includes the current screening mix of colonoscopy (83%), FIT (11%), and mt-sDNA (6%) modalities. The increased mt-sDNA scenario increases mt-sDNA utilization to 28% over 10 years. Costs for both the IDN and the payer perspectives incorporated diagnostic and surveillance colonoscopies, adverse events (AEs), and CRC treatment. The IDN perspective included screening program costs, composed of direct nonmedical (e.g. patient navigation) and indirect (e.g. administration) costs. It was assumed that IDNs do not incur the costs for stool-based screening tests or bowel preparation for colonoscopies.

Results: In a population of one million covered lives, the 10-year incremental cost savings incurred by increasing mt-sDNA utilization was $16.2 M for the IDN and $3.3 M for the payer. The incremental savings per-person-per-month were $0.14 and $0.03 for the IDN and payer, respectively. For both perspectives, increased diagnostic colonoscopy costs were offset by reductions in screening colonoscopies, surveillance colonoscopies, and AEs. Extending screening eligibility to 45- to 75-year-olds slightly decreased the overall cost savings.

Limitations: The natural history of CRC was not simulated; however, many of the utilized parameters were extracted from highly vetted natural history models or published literature. Direct nonmedical and indirect costs for CRC screening programs are applied on a per-person-per modality basis, whereas in reality some of these costs may be fixed.

Conclusions: Increased mt-sDNA utilization leads to fewer colonoscopies, less AEs, and lower overall costs for both IDNs and payers, reducing overall screening program costs and increasing the number of cancers detected while maintaining screening adherence rates over 10 years.     

Extensions of linear diagonal-parameter symmetry and quasi-symmetry models for cumulative probabilities in square contingency tables

For square contingency tables with ordered categories, CAUSSINUS [Annales de la Faculté des Sciences de l'Université de Toulouse (1965) Vol. 29, pp. 77–182] and AGRESTI [Statistics and Probability Letters (1983) Vol. 1, pp. 313–316] considered the quasi-symmetry and the linear diagonal-parameter symmetry models, respectively, which have multiplicative forms for cell probabilities. This paper proposes two kinds of models that have the similar multiplicative forms for cumulative probabilities that an observation will fall in row (column) category i or below and column (row) category j (> i ) or above. The endometrial cancer data are analyzed using these models.